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DO NOT STAPLE (use paper clip)
CF DATE STAMP:
FIMS ID# _________________
Fort Wayne Urban Enterprise Zone Scholarship
Coversheet
Application and all required materials due to
Fort Wayne Urban Enterprise Association by 5 p.m. March 13, 2015
Purpose of Scholarship
The Fort Wayne Urban Enterprise Association
(UEA) offers the Enterprise Zone Scholarship
Program as a part of its mission to improve the
quality of life for Zone residents.
To apply, applicant must have resided in the
Application Requirements
The entire application must be complete and signed. The
following items should be attached to the application:
1. Coversheet
2. Official Transcript
3. Essay
4. Two letters of recommendation
Fort Wayne Enterprise Zone Service Delivery
Selection Criteria
Area for the past two years and must have
received a high school diploma or equivalent Selection will be based on the following criteria:
(GED) prior to the start of the degree program  Demonstrate potential for successful completion of the
degree program
chosen. The student must also be enrolled as
 Past academic performance, work experience,
a full-time student at an Indiana institution.
volunteerism, leadership ability, and financial need
considered
Eligibility Determination:
Have you been a resident of the Fort Wayne Enterprise Zone Service Delivery Area for the past two years?
Yes
No
Have you enrolled as a full-time student at an Indiana institution?
Yes
No
\
Will you have a high school diploma or equivalent (GED) prior to the start of the fall semester?
Yes
No
Applicant Information
High School:
Applicant’s Name:
Ms.
Mr.
First
Middle
Last
Address
City, State and Zip
Home Phone:
Cell Phone:
E-mail Address:
Fort Wayne Urban Enterprise Zone Scholarship Application (Page 1 of 7)
Community Foundation of Greater Fort Wayne
Application Instructions:
1. Complete each section of this application carefully. Be sure not to leave any areas blank (write N/A if you
cannot provide an answer).
2. Include requested materials only.
3. When printing this application, be sure it is single-sided. (Do not print on the back side of pages.)
4. Sign the last page of this application. If you fail to do so, your application may not be considered.
5. Use a paper clip to fasten your application. Do NOT staple or tape.
6. Please keep a copy of this application for your records (we cannot provide copies).
SECTION 1: ACADEMIC INFORMATION
Attach an official copy of your most current high school or college transcript to this application.
Cumulative GPA:
SAT:
Math Score:
Critical Reading Score:
Writing Score:
Total Score:
College/university you plan to attend in the fall:
Major field of study:
City and State
In the fall I will be a:
I will be enrolled:
freshman
sophomore
full-time (12+ credits)
junior
senior
graduate student
half-time (6+ credit hours)
Are you a member of the 21st Century Scholarship Program?
Yes
less than half-time
No
SECTION 2: FAMILY INFORMATION
Applicant’s age:
Applicant’s marital status:
Parents’ marital status:
Applicant’s date of birth:
Single, Divorced, or Widowed
Single, Divorced, or Widowed
Married/Remarried
Married/Remarried
Separated
Separated
Number of people in your household:
If you are a dependent: Include your parent(s) and other children and family members that are living in your household and
are claimed as dependents. If you are an independent, include yourself, and (if relevant) your spouse and dependents.
Parent(s)/Stepparent(s)/Legal Guardian(s)
Name/Relationship to Applicant
Age
Not Attending
College
Attending College in 2015
Fort Wayne Urban Enterprise Zone Scholarship Application (Page 2 of 7)
Community Foundation of Greater Fort Wayne
part-time
full-time
part-time
full-time
Parent(s)/Stepparent(s)/ Legal Guardian(s) Employment Information
Mother/Guardian Employer:
Father/Guardian Employer:
Dependents of Parent(s)/Stepparent(s)/Legal Guardian(s)
Name/Relationship to Applicant
Age
Not Attending
College
Attending College in 2015
part-time
full-time
part-time
full-time
part-time
full-time
part-time
full-time
part-time
full-time
If there are additional dependents, please list their names on a separate sheet of paper (use the same format as above).
SECTION 3: FINANCIAL INFORMATION
Please follow these instructions when completing the financial section:
Step 1: Determine whether you are an independent or dependent student. If you are unsure, please visit the following
Web site: http://www.finaid.org/calculators/dependency.phtml
Step 2: Complete the financial questionnaire (you may need a parent/guardian to help you answer some of the
questions).
Step 3: If you are a dependent student, complete the “Financial Worksheet for Dependent Students.” If you are an
independent student, complete the “Financial Worksheet for Independent Students.”
Step 5: If there are unusual circumstances regarding your financial information, you may provide an explanation under
“Additional Financial Information.”
Financial Questionnaire
Within the last year did anyone in your household receive benefits from any of the following federal programs?
SSI
Food Stamps
Free or Reduced Price Lunch
TANF
WIC
None (N/A)
Did your parents/guardians file a 2013 Income Tax Return?
Yes
No
Not applicable, I am an independent student
Did your parents file (or were they eligible to file) a 2013 IRS Form 1040A or 1040EZ?
Yes
No
Not applicable, I am an independent student
Have either of your parents recently lost their job or been laid off?
Yes
No
Not applicable, I am an independent student
Did you file a 2013 Income Tax Return?
Yes
No
Did you file (or were you eligible to file) a 2013 IRS Form 1040A or 1040EZ?
Yes
No
Fort Wayne Urban Enterprise Zone Scholarship Application (Page 3 of 7)
Community Foundation of Greater Fort Wayne
Financial Worksheet for Dependent Students (2013 Tax Year)
Please have your parents/guardians complete the Parent(s)/Guardian section of the worksheet using information from
their 2013 Income Tax Return. PLEASE NOTE the following:
1. If your parents are married or remarried, both parents living in the household are required to list their income
and asset information (this may include your biological parents, a stepparent, or adoptive parents).
2. If your parents are divorced or separated, please have the parent that you are living with or have lived with the
most in the past 12 months, complete the parent/guardian section.
3. Do NOT include information for the parent not living in your household.
Parent(s)/Guardian(s)
Applicant
Adjusted Gross Income:
If Form 1040 , use line 37
If Form 1040A, use line 21
If Form 1040 EZ, use line 4
$
$
$
$
$
N/A
N/A
$
$
$
$
$
$
$
$
$
$
$
$
$
U.S. Income Tax :
If Form 1040 , use line 55
If Form 1040A, use line 35
If Form 1040 EZ, use line 11
Income earned from work (parents/guardians):
If Form 1040, use the sum of lines 7, 12, and 18.
If Form 1040A, use line 7
If Form 1040 EZ, use line 1
Income earned from work (applicant):
If Form 1040, use the sum of lines 7, 12, and 18.
If Form 1040A, use line 7
If Form 1040 EZ, use line 1
Child support paid:
Include children living in another household.
Exclude children living in your household.
Taxable combat pay:
Exclude if it was not reported as taxable income.
Untaxed Income and benefits:
Include child support received, workers’ compensation, disability,
untaxed portions of IRA distributions & pensions, and payments to
tax-deferred pension and savings plans. Exclude welfare payments,
untaxed Social Security benefits, and Supplemental Security
Income.
Cash, savings and checking:
Enter total current balance of all accounts.
Net worth of investments:
Include stocks, savings bonds, mutual funds, CD's, money market
accounts, UGMA and UTMA accounts, rental property, a second
residence, commodities, trust funds, stock options, securities,
qualified education benefits, qualified education savings accounts as
well as installment and land sale contracts. Exclude your home and
retirement plans.
Net worth of businesses/investment farms:
Exclude a business you own if it employs less than 100. Exclude
farm if you live on your farm, own your farm and actively
participate in its operations. Include farm if you rent farm ground
out to someone else. If you receive pasture rent from another
individual, or own a partnership interest in a family farm that you do
not actively participate in, please contact the Community
Foundation of Greater Fort Wayne at 260-426-4083.
Fort Wayne Urban Enterprise Zone Scholarship Application (Page 4 of 7)
Community Foundation of Greater Fort Wayne
Financial Worksheet for Independent Students (2013 Tax Year)
Information about you and your spouse (if applicable) must be included. Figures should be taken from your 2013 U.S.
Income Tax Return.
Applicant & Spouse (if applicable)
Adjusted Gross Income:
If Form 1040 , use line 37
If Form 1040A, use line 21
If Form 1040 EZ, use line 4
$
U.S. Income Tax :
If Form 1040 , use line 55
If Form 1040A, use line 35
If Form 1040 EZ, use line 11
$
Income earned from work:
If Form 1040, use the sum of lines 7, 12, and 18.
If Form 1040A, use line 7
If Form 1040 EZ, use line 1
$
Child support paid:
Include children living in another household.
Exclude children living in your household.
Taxable combat pay:
Exclude if it was not reported as taxable income.
$
$
Untaxed Income and benefits:
Include child support received, workers’ compensation, disability,
untaxed portions of IRA distributions & pensions, and payments to
tax-deferred pension and savings plans. Exclude welfare payments,
untaxed Social Security benefits, and Supplemental Security
Income.
Cash, savings and checking:
Enter total current balance of all accounts.
$
$
Net worth of investments:
Include stocks, savings bonds, mutual funds, CD's, money market
accounts, UGMA and UTMA accounts, rental property, a second
residence, commodities, trust funds, stock options, securities,
qualified education benefits, qualified education savings accounts as
well as installment and land sale contracts. Exclude your home and
retirement plans.
$
Net worth of businesses/investment farms:
Exclude a business you own if it employs less than 100. Exclude
farm if you live on your farm, own your farm and actively
participate in its operations. Include farm if you rent farm ground
out to someone else. If you receive pasture rent from another
individual, or own a partnership interest in a family farm that you do
not actively participate in, please contact the Community
Foundation of Greater Fort Wayne at 260-426-4083.
$
Fort Wayne Urban Enterprise Zone Scholarship Application (Page 5 of 7)
Community Foundation of Greater Fort Wayne
Additional Financial Information
If no financial information is provided, provide an explanation below. Also, if there are unusual circumstances
regarding the information provided (such as unemployment), or if there are unusual financial circumstances expected in
the future, please provide an explanation below (attach a separate sheet of paper if necessary).
SECTION 4: WORK HISTORY AND SCHOOL/COMMUNITY ACTIVITIES
Work History – Include summer and school year employment. Start with your most recent job.
Hours per
Employer
Nature of Work
Start/Finish Date
Week
Hourly Pay
School Activities – Include all school-related activities such as band, athletics, student government, etc.
Hours
Year
per
Activity
(please check)
Leadership position/awards
Week
FR
SO
JU
SR
FR
SO
JU
SR
FR
SO
JU
SR
FR
SO
JU
SR
FR
SO
JU
SR
FR
SO
JU
SR
FR
SO
JU
SR
Community Activities – volunteer, religious, scouts, etc.
Start/Finish
Activity
Date
Hours per Week
Leadership position/awards
SECTION 5: ESSAY
Fort Wayne Urban Enterprise Zone Scholarship Application (Page 6 of 7)
Community Foundation of Greater Fort Wayne
On separate sheets of paper, please submit a typed essay addressing the following questions:
Essay 1: What do you hope to gain from college? Why do you wish to continue your education? Why have
selected the field of study you intend to pursue?
(Essay must be 1-3 pages, double spaced)
SECTION 6: LETTERS OF RECOMMENDATION
Please include two signed letters of recommendation. (Recommendation letters should describe the initiative,
dependability, and other character qualities of the applicant.)
Signing below indicates your agreement to the following statement:
“I certify that all information in this application is true and complete to the best of my knowledge. If asked by any
authorized official of the Community Foundation, I agree to give documentation to support the information given on
this form.”
Applicant’s signature: ____________________________________________ Date: ______________________
Submit completed application by 5 p.m., March 13, 2015 to:
Fort Wayne Urban Enterprise Association
1830 Wayne Trace Rd.
Fort Wayne, IN 46803
Fort Wayne Urban Enterprise Zone Scholarship Application (Page 7 of 7)
Community Foundation of Greater Fort Wayne